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Pre-Certification Request
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Pre-Certification Request

For Outpatient CT, MRA, MRI


For you convenience and to expedite the pre-certification process, Deaconess Hospital offers Pre-certification online.

By completing this form for your patient's upcoming scheduled CT, MRA, or MRI procedure, the Deaconess Outpatient Pre-certification staff will handle the pre-certification process for you.  We will confirm authorization or if we have questions, we will contact you directly.
  • The first section below contains the minimal fields for pre-certification.  The other sections provide the ability to enter additional information that may be useful in finishing the pre-certification.  Please provide as much information as possible
  • All fields indicated by an asterisk must be completed in order to process the pre-certifcation request.
  • If you need assistance, please feel free to contact Deacones Outpatient Pre-certifcation staff by calling 450-3890, 450-5023 or 450-3458.
  • This is a secure, encrypted form.
  • This request is for Deaconess Hospital, Evansville, IN.  Outpatient CT, MRA, or MRI services only

Required Fields Contact Information:
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Service/Procedure Information:
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Patient Information:
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Additional Contact Information

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Additional Patient Information












Insurance Information







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Follow-Up
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